#1: Patient Eligibility, Benefit Verification & Authorizations - - PDF document

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12 Things Your Billing Team Should Be Doing & Doing Well

TEXAS ASC SOCIETY ANNUAL MEETING

#1: Patient Eligibility, Benefit Verification & Authorizations

Patient Eligibility, Benefit Verification & Authorizations

• The first critical step to ensure a case is viable
• Should be done more than a week prior to the date of

service to ensure you have time to obtain an authorization

• Speak to the patient prior to the procedure and explain their

portion that needs to be paid up front

• Ask “Who’s at risk?” for paying the claim to ensure it goes to

the correct address, managed care carrier or home‐plan. Ask for the claim’s address, and write it on the verification sheet.

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Patient Eligibility, Benefit Verification & Authorizations

• If you are dealing with an out‐of‐network carrier, ask the

right questions to fully determine the financial risk of performing the case at your center

• If you are dealing with one of the Blue’s and you are out‐of‐network, be very

careful to communicate to the patients that they may receive the insurance

• check. Have them sign an agreement the check will be turned over to the

center immediately.

• Ask the insurance representative how they price their claims. Is it UCR? Is it

based on their own fee schedule? If so, ask if you can get the rate per CPT. Do they base it on the Medicare fee schedule? If so, what percent of the MFS is used?

Patient Eligibility, Benefit Verification & Authorizations

• If you are dealing with an out‐of‐network carrier, ask the

right questions to fully determine the financial risk of performing the case at your center

• Be mindful that the various carriers have their own terminology:
• UHC may call it an MNRP policy
• Aetna may pay based on their own fee schedule which they state is the R&C (usual and

customary)

• Cigna pays out‐of‐network Medicare rates by stating it’s based on option 1 or option 2

(option 2 is their MFS rates)

• Blue Cross/Blue Shield has the max per day rates and sometimes case rates
• Ask if there is a max‐per‐day, maximum daily rate or case rates

Patient Eligibility, Benefit Verification & Authorizations

• Confirm if the patient has a secondary or tertiary insurance

and also verify those benefits to confirm if the coinsurance will be covered

• If you are dealing with a Worker’s Compensation plan, check

the fee schedule to confirm the procedures are covered. If not, deal with the adjuster to get a LOA (letter of agreement) and agreed amount of payment. This should also be done with high cost implants/supplies that are typically not covered under WKC fee schedules.

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#2: Accurate Coding & Billing per the Specific Payer Regulations

• Billing the claim correctly the first time is critical in keeping

costs down and ensuring timely collections

• Monitor the denial and rejection % and reasons
• Use your clearinghouse to scrub for modifier and LCD issues
• Ensure the op notes received from the provider are

detailed – the more detail, the better, and done timely!

Accurate Coding & Billing per the Specific Payer Regulations

#3: Make Sure All Required Support & Attachments are Sent with the Claim

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• This includes the op report, H&P, invoices and possibly a

letter of medical necessity

• This will help speed up the processing time and provides

support to pay the claim at the maximum reimbursement

• The Billing team/partner should have immediate access to all

medical records to avoid delays

Make Sure All Required Support & Documents are Sent with the Claim

#4: Billing Team Feedback

• Your Billing team/partner should be providing feedback on:
• Performed cases that aren’t payable.
• Cases that don’t meet medical necessity requirements.
• Cases that weren’t authorized.
• Issues with benefit verification/authorizations.
• Lack of detail in the op notes to support necessity.
• This is a huge responsibility on the part of the Billing team. They must provide

feedback to the facility/provider when the documentation or diagnosis doesn’t support medical necessity.

Billing Team Feedback

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#5: Benchmarking

• Use of Business Intelligence Analytics
• All Key Performance Metrics should be closely tracked to

quickly recognize issues and areas of improvement that are needed

• Denial Management is critical to address insurance rejections/denials ASAP.

This is good information to use to educate the providers/facility staff if there are ongoing issues with the LCD’s and non‐payable codes, as well as issues with patient benefit verification.

• The Billing team should be closely monitoring the cash throughout the month

Benchmarking

• All Key Performance Metrics should be closely tracked to

quickly recognize issues and areas of improvement that are needed

• The charges, cash and case volume trends should be examined
• Don’t forget to monitor the payer and specialty mix as this has a direct impact on

the upcoming revenue. The case volume may not change but a change in the payer or specialty mix could have a significant impact.

• Days in AR should be monitored closely. A small fluctuation is typical, but a

larger change signals an issue that needs to be addressed.

• Charge lag trend is important to note if there are internal delays or delays

with dictation

Benchmarking

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#6: Don’t Give Up on Out‐of‐Network Cases

• Payers are scrutinizing OON claims more, which is why it’s

important to ensure you have a specialized team working these claims

• Ensure the appeals are strong and provide justification to support the request

for the UCR. Present your facts and argument in writing before engaging the payer on the phone. Ask for a Supervisor if you aren’t getting the attention you need.

• Negotiate vigorously. Stay firm, provide justification of the UCR and keep the

bar set high.

Don’t Give Up on Out‐of‐Network Cases

• Payers are scrutinizing OON claims more, which is why it’s

important to ensure you have specialized personnel working these claims

• It’s not uncommon to deal with the same reps at the third party vendors that

negotiate the claims. Keep in mind this is a collaborative effort on both sides to be beneficial. Be firm but respectful.

• It may be necessary to have a Healthcare attorney available to escalate

Don’t Give Up on Out‐of‐Network Cases

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#7: Ensure In‐Network Claims are Paid Correctly

• Escalate immediately to the contracting rep if there are

discrepancies

• The Billing team/partner should know the contract rates,

terms, methodology, and when it’s time to re‐negotiate

• Make sure the contracts are loaded correctly into the patient

accounting system, including implants, supplies and carve‐

• uts

Ensure In‐Network Claims are Paid Correctly

#8: Timely & Thorough Follow‐Up

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• Timely follow‐up is key to ensure the insurance has

everything they need to pay the claim and pay it correctly

• Avoid untimely filing denials and unnecessary loss of
• revenue. All team members should be mindful of the timely

limits for contracting claim submission and all appeals.

• All Collectors should be working the accounts to resolution,

and working each account thoroughly and aggressively

Timely & Thorough Follow‐Up

#9: Payment Posting

• Make sure payments are posted on a daily basis
• Spot check that all payments and adjustments are posted

accurately

• Review the EOBs for any issue indicators
• Ensure any over or under payments are handled immediately
• Transfer patient balances right away and start generating

statements

• Stay on top of credit balances to keep a clean A/R
• Reconcile the payments to ensure no missed postings

Payment Posting

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#10: Contract Negotiation

• Negotiate smart contracts that are beneficial to the ASC

based on the specific specialties

• Work with the rep to request carve‐outs. Provide backup on

your cost to support your requests.

• Keep in mind any new specialties you might bring to the

center before the end of the contract term

Contract Negotiation

#11: Patient Collections

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• The patient portion is critical to ensure success of the ASC
• The Billing team/partner should communicate with the

center if the center isn’t collecting enough up front. Studies show that after 90 days, the collectability decreases significantly on the backend.

• Patient statements should be sent every 2 weeks, and

collection calls should be made to discuss the balance with the patient and get a commitment

Patient Collections

• Give patients options to pay online
• Offer payment options up to 2‐3 months
• Monitor bad debt trends closely

Patient Collections

#12: Communication

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• There should be no lack of communication between the

Billing team/partner and the center

• Communication on all the above is critical to maintain a

successful and healthy partnership

• Transparency and Trust are an important factor for success!

Communication

Questions? Thank you!

Contact Us to Learn More

Email: Sales@SurgicalNotes.com CMeisel@SurgicalNotes.com Phone: (800) 459‐5616 (720) 545‐4295 Website: www.SurgicalNotes.com